Friday, November 21, 2008

AMA's U-Turn on Industry Funding

As reported in Medical Meetings, the AMA's Council on Ethical and Judicial Affairs(CEJA) will reverse its earlier position, and will recommend that industry support of CME be allowed to continue.Just last May, CEJA had prepared this report urging the AMA to adopt a stance against allowing commercial support of CME, concluding that:

To promote continued innovation and improvement in patient care, medicine must sustain ongoing, productive relationships with the pharmaceutical, biotechnology, and medical device companies. However, industry support of professional education has raised concerns that threaten the integrity of medicine’s educational function....Existing mechanisms to manage potential conflicts and influences are not sufficient to address these concerns. Recognizing the profession-defining importance for medicine of achieving its educational goals, the Council recommends that:Individual physicians and institutions of medicine, such as medical schools, teaching hospitals, and professional organizations (including state and medical specialty societies) must not accept industry funding to support professional education activities.

That report was debated in an AMA reference committee (a committee which debates issues before bringing them before the full house of delegates), and after hearing from a slew of medical education companies, the committee recommended tabling the proposal for further review. Since then, Dr. Mark Levine, the chairman of the committee, ended his term and was replaced by Dr. Regina Benjamin. Apparently, one of the committee members (not Dr. Benjamin) told journalist Dave Kovaleski that while the next version of the report will not be released until next June, an interim report makes it clear that industry funding will continue in some fashion or other. That's clear enough. But in a strange twist, CEJA is now calling for comments as they prepare the final report. They've already given us the punchline, and now they want input?

At any rate, it appears that CEJA is working on this report jointly with the AMA's Committee on CME, and this may explain why CEJA has changed its mind. The ethics of the issue have not changed over the last 6 months--after all, ethics rarely change at all. The core ethics of this issue were summarized in the original report's abstract thusly:

Medicine’s autonomy and authority to regulate itself depends on its ability to ensure that current and future generations of physicians acquire, maintain, and apply the values, knowledge, skills, and judgment essential for quality patient care. To fulfill this obligation, medicine must ensure that the values and core commitments of the profession protect the integrity of professional education.

In May, this ethical core struck CEJA as being inconsistent with industry funding of medical education. What appears to have happened is that ethics (CEJA) has married expediency (the CME Committee.) The final report will therefore be a moral compromise. This does not make me proud of my profession.

11 comments:

The prior Chairman of the CEJA is gone, as demanded. The AMA spared itself a lawsuit, promised in a blood oath. The Office of Legal Counsel hopefully privately explained the suicidal consequences.

Dan is a private citizen, and immune in his opinions. I strongly support his Free Speech rights, despite our disagreement and his censorship of my speech. He has no obligation to anyone's speech.

The AMA is not immune as a quasi-governmental organization (professional society lawyers deny this status in the strongest terms, knowing its implications). AMA could face oblivion if it violates the Constitution.

This is great news! The original report from CEJA was riddled with bad data. Much of the data that were used in their report dated back to the 90's and even 80's in some cases. CME may never be perfect, but it has made huge steps in the right direction. The bottom line is the vast majority of doc's do not want pharma (dollars) out of CME. Many CME providers have now been polling their attendees and the numbers show that commercial support is not an issue. The argument that pharma bias will creep into the minds of the learners is complete bunk. CME providers develop educational activities for MD's not Joe the plumber. They are smart enough to sniff out any bias if it's there...and if there is bias, that CME provider will soon be looking for a new career. The heightened scrutiny in the CME industry has done a very good job weeding out poor quality CME providers...getting rid of commercial support will weed out the good ones.

What is your opinion of commercial funding of CME activities?

A. Appreciate the support provided by commercial interests (184)B. Wish the presence of commercial interests was less (99)C. Doesn’t matter whether activity is or isn’t funded by commercial supporters (146)

330 out of 429 psychiatric clinicians at a resent CME conference want to keep commercial support or do not mind that it persists.

Seems to go along with the pathetic excuses of our colleague Fred Godwin, who Senator Grassley has exposed as yet another fraud of an alleged leader in our profession. You are not proud of our profession, Dr Carlat? I am shamed and disgusted. It just gives more ammo to the anti-psychiatrists that roam this medium. Every day these alleged spokespersons get away for setting precedence and direction for our treatment decisions, we as professionals might as just well grab a shovel and dig that grave deeper.

I had my own aggravations today in practice with colleagues I had to cover who just write Rxs like pez. It sickens me what patients are told are alleged standards of care. Biochemical imbalances? Just in the bastards who sell this pathetic message.

Sorry to be harsh, but how much longer does it have to get worse before we as responsible clinicians see something get better? Was my training just a fraud and waste of time? I would hope not.

A dissapointing week, that is for sure. Thursday can't come soon enough for me.

We can hardly blame our problems on anti-psychiatry. We made this crowd that is growing daily. We allowed our profession to be run by drug companies. We allowed pharma to dictate our treatment standards.

I will say this: I respect anonymity, as I myself use an alias to avoid retribution by potential colleagues or the extremists in this anti-psychiatry crowd I have dealt with at other sites, but I think it would be nice if commenters who use Anonymous as a title should at least give some backround to the basis of what is contributed.

If the above person is a colleague, I agree, only that those who stay silent or go through the motions are as much the cause to our detriments as the proactive liars that are being exposed one by one by Sen Grassley.

I will say this though: the anti-psychiatry crowd equally contributes to the problems at hand by lumping all psychiatrists as villians, and that is wrong, period! No one in this group wants to hear fair and reasonable discourse by professionals, because as soon as one identifies oneself as a clinician, the comments are dismissed, even if supporting the attacks on poor decisions and choices that jaded colleagues are trying to push on an innocent public. Don't believe me, just go to the sites that don't moderate comments and read those threads.

Pharma will pollute the treatment process until clinicians see there are consequences for pursuing greed and power. WHEN Sen Grassley starts handing out indictments, or professional organizations start removing licensures of guilty practitioners, only then will doctors change habits. It is the nature of the beast here; we don't learn until we touch the hot surface and get burned.

I assume this week will be quiet due to the holidays, so I wish all of you well and enjoy your food and family. Be well, and moreso be honest and direct.

When you make comments like this on the clinical psych blog about the anti psychiatry crowd resembling nazis, people aren't going to react too kindly. You have constantly made provoking comments on various blogs knowing full well what you were doing. Frankly, I am tired of you being allowed to get away with it.

Just so people on this blog know, I am tapering off of psych meds due to horrific side effects, including a hearing loss. I have also suffered from a Prozac induced suicidal ideation that people like Goodwin claims doesn't exist. So Dr. Carlat, I greatly look forward to your account.

I am in generally anti psychiatry because of what I feel is a condescending attitude that dominates the profession. You would feel the same way if you were constantly blown off and all your complaints were attributed to your "illness".

But I don't hate all psychiatrists so please stop your generalizations. Maybe if you listened instead of flaming us, you might learn something that would stop the burnout you described in another post. I actually felt sorry for you TF until you I read your response.

Dr. Carlat, thank you for the work you are doing. You give me hope about psychiatry.

Other anonymous, thank for you what you said in response to TF. It was greatly appreciated to see a professional step up to the plate and take responsibility instead of blaming people like me who have suffered greatly.

Right now I'm more appalled at the AMA and their ethics committee. Why on earth would this reversal be announced via Medical Meetings [a trade magazine] rather than on the AMA's own website, or via an AMA press release to the general media?

I teach medical communication, and one of the first lessons is about sending the right message to the right audience. If the AMA thinks their main audience is a trade magazine for people who schedule medical meetings [read "industry-funded CME events"], that tells us all a great deal about the priorities of the AMA right now.

And I don't think most of us here are happy about that. It doesn't matter _what_ you think of psychiatry -- this decision by the CEJA affects all of medical practice.

All I can say, to avoid turning this site into the flaming rhetoric that other sites are and were before I began attempting to offer fair and reasonable dialogue at blogs like this, is the projection and displacement voiced by the antipsychiatry crowd only ruins sincere efforts to reel in colleagues of poor judgment and choices. I feel the above comment by AA only validates my position.

I do listen, reflect both for myself and back to others, and learn from a fair and reasonable process. It is a shame people of power and authority have failed both patients and colleagues, and too many good and caring doctors just sit there silently and helpless. But calling for the field to be eradicated is not a solution. Hence why I do see parallels to past extremisms and hostilities by those guided by the politics of hate.

We can only hope sites like this will provide responsible moderation and not stooping to Jerry Springer-type bashes. It serves no postive or productive agenda, just sick and pathetic entertainment, and success is measured in hits, not substance.

It will be interesting to see how people will reply if Dr Carlat will share ambivalence with his reflections in next week's commentary, because he probably and rightfully will. As I have said repeatedly, this is a field of gray, and extremists are only black and white.

Sites like this are looking for change, for the better. That is why I come here, I comment, and come back to hope others will join in and refute greed, narrowmindedness, and carelessness. Because those who do weigh in as clinicians are not just doctors or other providers, but as much advocates for those we treat. And I know there are a good number of us who do it appropriately and credibly!

If this is provocative, I am glad to be guilty of trying to do better. A mistake for having faith and hope? Try offering those efforts 30+ hours a week 46 weeks a year for the growing numbers that come to psychiatrists for help. I preach interventions in multiple ways, not pills. Hence the alias!

As I said in my last comment, things will only change when guilty people suffer consequences. It is time for responsible and accountable authority and peers to do right, not what is easy or convenient.

Isn't that what this blog is attempting to direct? Can a few have a positive impact on the many?

I find value in posting, as a psychiatrist, using my real name. It keeps me honest and thoughtful, and (I hope) humanizes me to readers. For many years now I've felt that much of the heat in online discussion stems from anonymity. Like the unseen psychoanalyst, online anonymity promotes transference and its attendant idealization and devaluation (fawning and flaming). We'd all be better off with less of this outside the analytic hour.

Regarding anti-psychiatry, there are extremists in every movement. I've had civil debates with anti-psychiatrists in the past, although surely there are some (on both sides!) who are unwilling or unable to converse in a civil way. Forums such as this one cater to the best in us, even if we disagree -- and for that we can all be thankful.